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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 02/07/2024
Date Signed: 02/07/2024 05:28:24 PM


Document Has Been Signed on 02/07/2024 05:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:KINGSLEY MANORFACILITY NUMBER:
197608482
ADMINISTRATOR:LIYON O'QUINNFACILITY TYPE:
740
ADDRESS:1055 NORTH KINGSLEY DRIVETELEPHONE:
(323) 661-1128
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY:299CENSUS: 181DATE:
02/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Liyon O'Quinn, AdministratorTIME COMPLETED:
05:35 PM
NARRATIVE
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During the course of a complaint investigation visit and during visits with residents and staff, it was discovered that the facility had made significant change in the facility policy and plan of operation. . One change was that facility would now make exception for accepting "tips" from the resident's council for the employee's appreciation fund and they would distribute those funds via payroll and tax it. Facility did not notify CCL about the policy change nor did the facility update the plan of operation or provided explanation on how they would safeguard the resident's monies.

It is required that facility update their plan of operation and send it to CCL for approval before new policy can be implemented.

Deficiency cited on 809D

Exit interview conducted and copy of report and appeal rights provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/07/2024 05:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: KINGSLEY MANOR
FACILITY NUMBER: 197608482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/21/2024
Section Cited
CCR
87208(a)(9)

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(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. (9) A statement whether or not the applicant will handle residents' money and/or valuables. If money or valuables will be handled, the method for safeguarding pursuant to Sections 87215, Commingling of Money, 87216, Bonding and 87217, Safeguards for Resident Cash, Personal Property and Valuables. This requirement is not met as evidenced by:
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Facility will update their plan of operation and send it to CCL for approval
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Facility is now classifying employee appreciation funds as tips and taxable and requiring the resident council to cut a check to corporate to distribute the funds. the plan of operation is not up to date and is missing a statement on how resident's cash will be safeguarded.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2